A Dentist Out of the Building: Sorting a Delegation Schedule
Dr. Alvarez leaves Brightmoor Family Dental at 1:00 p.m. for a study club and will not return until 5:00. You are Priya, RDH. The staff also includes Marcus, a registered dental assistant, and Kelsey, hired three weeks ago as a dental assistant; Kelsey has no board-approved radiography course and no completed application on file. The office manager hands you the afternoon schedule and asks you to “keep things moving and sign off as the supervising clinician.” The 2:00 patient is a 9-year-old recall booked for coronal polishing and fluoride varnish. At 2:30 a patient is scheduled to have a temporary crown cemented. At 3:00 a patient is scheduled for a final impression for a 3-unit bridge. At 3:30 a patient returns 7 days after an extraction for suture removal. At 4:00 a new patient is scheduled for a panoramic radiograph. No dentist will be in the building at any point.
1. Sort the five afternoon appointments: what may be performed, by whom, and what must be rescheduled? Explain the legal basis for each decision.
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The organizing principle is that an auxiliary may perform only what the Dental Practice Act and Board rules permit, and only at the supervision level the rule attaches to that function. A hygienist is not a substitute supervising dentist.
- 2:00 coronal polish and fluoride (age 9). Coronal polishing by an assistant is, at most, an expanded function tied to board-approved training and direct dentist supervision. No dentist is in the building, and there is no training documentation for Marcus in the file. Reschedule, or perform the prophylaxis yourself only if your own scope and a prior dentist authorization support it.
- 2:30 temporary crown cementation. Seating and cementing a crown is the practice of dentistry. Neither Kelsey nor Marcus may do it. Reschedule.
- 3:00 final impression. Final impressions (as opposed to study-model impressions) are part of restorative treatment and are not delegable to an assistant. Reschedule.
- 3:30 suture removal. Post-surgical assessment and management. Not delegable. Reschedule.
- 4:00 panoramic. Two independent failures: there is no dentist order or documented diagnostic justification, and Kelsey has not completed the radiography education Michigan requires before an assistant may expose radiographs.
Declining to “keep things moving” is the professionally correct answer, and the reason should be put in writing to the office manager.
2. Can Priya accept the manager's request to “sign off as the supervising clinician”? What supervision level applies, and who is legally able to supply it?
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No. Under Michigan's rules, direct supervision means the dentist has examined the patient, authorized the procedure, and is physically present in the office while it is performed; general supervision means the procedure was authorized but the dentist is not on site. Many of the functions on this schedule - and a hygienist's administration of local anesthesia - are tied to direct supervision.
A hygienist cannot supply that supervision, because the delegation chain runs from the dentist. If Priya signs off, she is representing that a dentist is present and directing care, which is false. That creates exposure for aiding unlicensed practice and for a false clinical record - both independent grounds for discipline, regardless of whether any patient is harmed.
Telephone availability does not cure the problem: physical presence is the test, not reachability.
Practical steps: (1) decline by email so a record exists; (2) perform only services within the hygienist's own scope for which the dentist has already examined and authorized the patient and for which the applicable supervision level is satisfied; (3) reschedule the rest; (4) raise the issue directly with Dr. Alvarez. A hygienist who is pressured to paper over a supervision gap should document the pressure - that documentation is the difference between being a witness and being a respondent.
3. Kelsey asks whether she can “at least take the panoramic, since the machine basically runs itself.” How do you answer, and what would the practice need to have on file before she could expose radiographs at all?
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The answer is no, and “the machine runs itself” misunderstands what the credential is for. Exposing radiographs requires judgment about patient positioning, technique selection, radiation protection, and image quality - which is why Michigan conditions an assistant's authority to expose radiographs on completing a board-approved course in dental radiography, and on a dentist's order for a specific diagnostic purpose.
Before Kelsey could expose a single image, the practice would need:
- a certificate or completion record from a board-approved radiography course, kept in her personnel file;
- the dentist's clinical justification for the specific image (a pan taken eight months ago on a recall patient with no new findings is not automatically indicated);
- appropriate supervision and competency verification while she is new;
- a radiation safety program consistent with MIOSHA and the practice's equipment obligations - machine inspection, dosimetry where required, and operator training.
Also flag her unfinished application status: until the practice confirms what her current credential does and does not cover, she should be limited to basic supportive services, and the supervising dentist - not the hygienist - is accountable for what uncredentialed staff do in the operatory.